Chapter 10 — Quiz
Twenty-two questions. Verify all codes currently.
Multiple choice
1. Sepsis with no documented acute organ dysfunction requires:
- A. the underlying infection code only
- B. the infection code plus a severe sepsis code
- C. a severe sepsis code sequenced first
- D. a septic shock code
2. In every sepsis encounter, sequenced first is:
- A. the severe sepsis code
- B. the underlying systemic infection
- C. the organ dysfunction
- D. the reason for admission
3. Severe sepsis requires documentation of:
- A. a positive blood culture
- B. acute organ dysfunction associated with the sepsis
- C. intensive care admission
- D. septic shock
4. Organ dysfunction documented but not documented as associated with the sepsis:
- A. is assumed to be related
- B. is a query
- C. requires R65.20 anyway
- D. is not coded at all
5. Once a patient has been assigned B20:
- A. they revert to Z21 when asymptomatic
- B. B20 applies to all subsequent encounters
- C. the inconclusive serology code applies
- D. Z21 and B20 are reported together
6. "Uncertain behavior" in the Table of Neoplasms means:
- A. the coder is uncertain
- B. the pathologist could not classify the neoplasm
- C. the documentation is silent
- D. the site is unknown
7. "Unspecified behavior" means:
- A. the pathologist could not classify it
- B. the documentation does not state the behavior
- C. the neoplasm is benign
- D. metastatic disease
8. A patient presents solely for chemotherapy. Sequenced first:
- A. the malignancy
- B. the encounter code for the chemotherapy
- C. any anemia
- D. the adverse effect
9. A malignancy is coded as personal history (Z85) when:
- A. treatment ended
- B. it was excised or eradicated, there is no further treatment to the site, and no evidence remains
- C. five years have passed
- D. the patient is in remission
10. When diabetes type is not documented, the default is:
- A. type 1
- B. type 2
- C. drug-induced
- D. unspecified
11. The "with" convention permits linking diabetes to:
- A. any clinically plausible condition
- B. the conditions the classification links under "with"
- C. any condition on the problem list
- D. no conditions without explicit documentation
12. "Anemia in neoplastic disease" carries an instruction to:
- A. code the anemia first
- B. code first the neoplasm
- C. use an additional code for the anemia
- D. omit the neoplasm
13. A G89 pain code is sequenced first when:
- A. pain has lasted over three months
- B. the encounter is for pain management rather than the underlying condition
- C. the site is unknown
- D. the pain is postoperative
14. ICD-10-CM defines chronic pain by:
- A. three months' duration
- B. six months' duration
- C. no duration rule — the provider's documentation governs
- D. the site involved
15. Routine postoperative pain is:
- A. always coded
- B. not coded; it is expected
- C. coded with G89 only
- D. coded as a complication
Short answer
16. State the six-step method for entering an unfamiliar body system.
17. State the two conditions that must both be met before adding an organism code.
18. Give the sepsis sequencing rules in order, and name the most common error.
19. Distinguish "uncertain behavior" from "unspecified behavior," and say why the distinction matters.
20. State the three conjunctive conditions for a Z85 history code.
21. (Chapter 9) A note documents type 2 diabetes and stage 3a CKD with no stated linkage, and both are addressed at the encounter. May you use the combination code? Name both questions involved.
22. (Chapter 4) A coder assigns a chronic pain code because the pain has lasted eight months. Name the error and the rule it violates.